Boston University School of Medicine
Section of General Internal Medicine
801 Massachusetts Avenue, 2nd Floor
Boston, MA 02118
Tel: 617-414-7288
Fax: 617-414-4676
Dear Clinical Quality Award Committee members,
We are honored to be considered for this award. In response to the fact that many (more than 20%) of
patients with diabetes in General Internal Medicine (GIM) are in poor control (with hemoglobin A1Cs of
greater than 9), we decided to form an interdisciplinary quality team to address this problem. This team
includes a representative from the call center (Alexia Rojas), pharmacy (Megan Bergstrom), nursing (Carmen
Teso), physicians (Drs. Lasser and Siegel), and our endocrine colleagues who practice in GIM (James
Rosenzweig (physician), Roberta Capelson (nurse practitioner), and Daniel O’Shea (patient navigator)). We
also invited colleagues from social work, behavioral medicine, and a medical assistant to join in our
discussions. While we have recently received recognition as a level I patient-centered medical home (PCMH),
many of us felt that we were really only a PCMH “on paper.” We were not delivering team-based care and
performing true population-based management. Rather, we were waiting for patients to come in for individual
visits. If patients missed a visit, we waited until they next sought care to address their diabetes.
In the fall of 2012, we embarked upon a series of planning meetings, facilitated by Jim Danielson, a
process improvement specialist. We attempted to map our current processes of diabetes care beyond individual
provider visits, and concluded that no such processes of care existed. We therefore created a whole new process
of care. We examined each team member’s current role in caring for diabetic patients and redesigned their role
so that they would be working “at the top of their license,” e.g. using their most advanced skills in their work.
We then worked with our colleagues in IT to develop a report for each primary care provider of patients with
poorly controlled diabetes. We then piloted team meetings to discuss patients of Drs. Lasser and Siegel. At
each meeting, the PCP gave a brief description of the patient and identified barriers to optimal diabetes control
(e.g. mental health or substance abuse problems, transportation issues, difficulty affording medication
copayments), and the group brainstormed solutions. Different members of the care team then took on tasks that
they would complete between team meetings. For example, Alexia (from the call center) would call patients
who were missing appointments to understand why this was the case. She would also schedule appointments for
the patient to see a dietician, pharmacist, social worker, or psychologist as appropriate. Finally, she would
arrange for patients to have pre-visit labs. Carmen (the nurse) would deliver intensive one on one education for
patients with low literacy who were struggling to control their diabetes. During the meetings, Roberta
Capelson, Dr. Rosenzweig and Megan Bergstrom would provide expert advice on how to intensify medication
therapy.
This project has resulted in a significant decrease in mean hemoglobin A1C among Dr. Lasser and
Siegel’s patients (nearly 1 point), relative to control group PCPs. There are several reasons why our quality
improvement effort has been successful. First, we implemented the intervention using a “bottom-up”
approach. We believe that engaging front line practice staff in the design of quality improvement interventions
is much more effective than a “top down” approach in which clinical leaders implement changes without
seeking input from staff. In addition, we believe that seeking input from all team members can result in
improved care. Many of our team members come from the same communities as our patients, and thus were
able to provide insights into barriers patients may face. A second reason why our efforts have been successful is
that we sought to address the social determinants of health that prevent our patients from achieving better
health outcomes. Our call center staff and patient navigator assisted patients in obtaining health insurance
coverage, access to social workers to address financial, housing or employment problems, or transportation to
appointments. We believe that our approach with attention to the complex social realities faced by many of our
patients has been paramount to our success in improving diabetic control among our patients.
Thank you for considering our team for this award.
Sincerely,
Karen E. Lasser, MD, MPH
Quality Leader,
Section of General Internal Medicine
Associate Professor of Medicine/Public Health
Boston Medical Center
Boston University School of Medicine and Public Health
Jennifer Siegel, MD
Assistant Professor of Medicine
Boston Medical Center